Several months ago, in a lawsuit that was in its ninth year, a federal judge blasted the medical care at the Louisiana State Penitentiary at Angola. Many inmates hoped it would be a watershed moment.

In her opinion, U.S. District Judge Shelly Dick excoriated the state for its “callous and wanton disregard” for the health of those in its custody. “Rather than receiving medical ‘care,’ the inmates are instead subjected to cruel and unusual punishment,” Dick said in her November opinion. The “human cost,” she said, is “unspeakable.”

She then ordered the appointment of three independent monitors to devise and implement a plan to reform the system.

That plan, however, may never come to fruition. Before those monitors could even be chosen, the state appealed the ruling, invoking a federal law — the Prison Litigation Reform Act — that hobbled a similar lawsuit over Angola’s health care nearly 26 years ago. The current case could suffer a similar fate.

That class-action suit is now before the conservative 5th U.S. Circuit Court of Appeals. In a March hearing, two of the three judges who heard the case asked questions that appeared sympathetic to the state’s argument that Dick’s ruling violated provisions of the Prison Litigation Reform Act.

If the ruling is thrown out, it would close off the most viable path for inmates to force improvements to a medical system that Dick found to be in violation of the Constitution’s Eighth Amendment, which bans cruel and unusual punishment. And it would come as prison policy experts expect a number of new, tough-on-crime laws to increase the state’s prison population, further straining Angola’s medical system.

Because this lawsuit concerns one of the country’s largest prisons — and one with a long history of litigation over its conditions — inmate advocates are watching it closely. It is one of many class-action lawsuits across the country seeking to force state officials to improve conditions in their facilities. At some point, said Margo Schlanger, a law professor at the University of Michigan and a former trial attorney in the Department of Justice’s civil rights division, all of those suits will have to contend with the Prison Litigation Reform Act.

That’s by design. The federal law was passed to reduce the number of lawsuits filed by inmates, particularly class-action cases that resulted in sprawling, court-monitored reform efforts lasting a decade or more. Supporters of the law said it was needed to weed out frivolous suits that tied state officials up in court and invited judges to meddle in how prisons are run.

But the law “did considerable damage to the ability of courts to be a backstop for safe and constitutional prisons,” Schlanger said. Since the PLRA was passed about three decades ago, the number of lawsuits filed by inmates nationwide has dropped by nearly 40%, according to a 2021 report she wrote for the Prison Policy Initiative, a research and advocacy organization; the percentage of inmates in prisons where courts are monitoring reforms dropped as well.

Not every lawsuit is doomed to failure, said David Fathi, director of the American Civil Liberties Union’s National Prison Project. In September, Fathi’s team successfully sued to remove up to 80 minors from a former death row unit at Angola. The ACLU also won a lawsuit requiring Arizona to improve medical care in its prisons.

Still, those victories are not the norm, Fathi said. “This law is unique in the world,” he said. “There is no other country that has established a separate and inferior legal system that applies exclusively to incarcerated people.”

Inmates Sue Over a Broken, Abusive Medical System

Some of the earliest allegations regarding Angola’s failing health care system were included in a lawsuit largely concerned with other issues. In that 1971 case, inmates alleged unchecked violence and racial discrimination within the walls of the prison. They claimed that they were crammed into overcrowded dormitories, that they were subjected to rape and that the prison was overrun with weapons that resulted in more than 270 stabbings, 20 of them fatal, in less than three years, according to court documents.

As part of that case, a federal judge determined in 1975 that prison officials had failed to provide adequate health care, which amounted to cruel and unusual punishment. The prison remained under court monitoring for more than a decade as officials addressed shortcomings.

Nearly 20 years later, that suit spurred another, focused solely on the prison’s medical care. In their 1992 complaint, inmates claimed that it was nearly impossible to obtain the bare minimum of care. They contended they were routinely disciplined for seeking treatment if medical staff determined that their complaints weren’t warranted; their lawyers contended that the fear of punishment caused them to delay seeking care. When requests for medical care were heeded, inmates were generally assessed by staff who had little or no medical training. Those staffers would decide if the complaint warranted an appointment with a doctor or nurse, which didn’t take place for weeks or even months, according to the lawsuit. The wait for surgery could be years.

The same year the suit was filed, a patient with AIDS appeared to be “in the process of dying” when staff mistakenly inserted a feeding tube into his lung instead of his stomach, according to a medical expert’s testimony for the plaintiffs and medical records introduced as evidence. The inmate’s breathing became labored and he started “coughing up large amounts of frothy liquid,” according to medical records. He was taken by ambulance to a local hospital, where he died several days later. The cause of death was AIDS, sepsis and aspiration pneumonia, which occurs when food or liquid is inhaled instead of air, according to medical experts.

The next year, another inmate was diagnosed with “persistent dislocation of the finger,” which was described in medical records as “black and red in color, with yellow drainage.” A physician at Angola warned that if the injury was left untreated, the bone could swell and require amputation. And yet, although the inmate was seen by medical staff at least 13 times, he never received the needed care, according to a plaintiffs’ court filing. Nearly a year after the inmate first sought help, his finger was amputated.

In court, the state denied that it was “deliberately indifferent” to the medical needs of the inmates — the standard under which medical care is deemed unconstitutional — and argued that Angola’s care was “constitutionally adequate.”

The state contended in a court filing that the patient whose finger was amputated was seen repeatedly by the prison’s medical staff and provided the necessary treatments, including antibiotics and wound care. The amputation wasn’t the result of a denial of care, the state argued, but was necessary to “promote complete healing” of a chronic condition. As for the AIDS patient, the state claimed that he received care that was “supportive, palliative and which attempted to prolong his life.” The state did, however, note an “unfortunate incident of a misplacement” of a feeding tube.

Verite News and ProPublica tried to contact several of the 11 named plaintiffs in that suit and reached one, Thad Tatum, who served 28 years for armed robbery and attempted murder. During a recent interview in his New Orleans home, Tatum shifted back and forth in the seat of a motorized scooter, straining to relieve the pressure in his back. He laid the blame for the loss of function in his legs and right hand on prison officials.

In 1988, Tatum was hospitalized for nearly five weeks after another inmate smashed an ice pick into his forehead and neck, damaging his spine. Shortly after the attack, doctors assured him that if his physical therapy continued at Angola, he would walk again, Tatum said. Neither happened, Tatum claimed in the lawsuit.

After he was sent back to Angola, the prison’s medical staff failed to provide him with physical therapy, Tatum alleged in court. He told Verite News and ProPublica that when he tried to work out on his own, by lifting weights or pacing the yard with the assistance of a walker, he was ordered to sit in his wheelchair and written up for disobedience and insubordination.

The lack of medical attention “is why I am still in this chair,” Tatum said. “Those people just don’t care.”

The state claimed in court that Tatum did receive physical therapy, and though he had “variable success” walking with a cane, he was never able to walk consistently. His subsequent paralysis was not caused “by lack of therapy but rather by the injury itself,” the state argued. The Louisiana Department of Public Safety and Corrections did not respond to a request for comment on Tatum’s allegations that he was disciplined for working out on his own.

Lawmakers Act to Stop “Endless Flood of Frivolous Litigation”

By suing the prison, Tatum said, he hoped to force change by exposing the horrors he and others endured. Initially it appeared that the strategy was working. After an evidentiary hearing in 1994, U.S. District Judge Frank Polozola instructed both sides to come to an agreement on how best to address the problems that the inmates had exposed.

But as negotiations dragged on, Congress passed the PLRA. The 1996 law came as the nation’s incarcerated population was exploding, along with the number of civil rights lawsuits filed by inmates over conditions. Both had tripled over the previous 15 years.

“Jailhouse lawyers with little else to do are tying our courts in knots with an endless flood of frivolous litigation,” Sen. Orrin Hatch, R-Utah, said in 1995 when he introduced the bill. “It is past time to slam shut the revolving door on the prison gate and to put the key safely out of reach of overzealous Federal courts.”

To do so, the PLRA instituted hurdles that inmates had to face before filing suit. If they cleared them, the law required judges to consider lesser interventions before they could order court-monitored reforms, typically in response to a class-action lawsuit. With little possibility of court intervention, many plaintiffs agreed to settlements that offered little in damages or reforms, according to three legal experts who specialize in the PLRA.

That’s how it played out in Louisiana.

On Sept. 21, 1998, inmates at Angola were given an advance copy of a proposed settlement between the state and the Department of Justice, which had intervened in the case on behalf of the inmates. Prison officials had agreed to make a host of improvements to the health care system. If they fixed the problems by the following February, the case would be dismissed with no further court oversight. If they didn’t, the lawsuit would move forward to a possible trial.

In addition to those stipulations, the settlement lauded prison officials for what the state and the Justice Department agreed were significant improvements in the delivery of medical care at Angola, including updated laboratory equipment, the addition of telemedicine and training for technicians who responded to inmates’ requests for medical care.

Two days later, several inmates fired off a scathing letter to the Department of Justice in which they said the list of improvements so far read like a “FANTASY.” Health care at the prison remained abysmal, they wrote, saying the treatment of chronically ill patients was “non-existent.” Raw sewage often leaked into Angola’s hospital and its kitchen, something they had been complaining about for years. “HOW COULD THIS PROBLEM STILL EXIST AFTER ALL THIS TIME?????” they asked.

They concluded by telling the Department of Justice that it had been fooled. Before its inspectors visited Angola, prison officials had time to “cover up and steer you away from the problems here,” inmates wrote. “The hospital has NOT been straightened up as claimed.”

The settlement was finalized in court the next day.

The plaintiffs’ medical expert, Dr. Michael Puisis, shared many of the inmates’ reservations. In a January 1999 report filed in court, a month before the deadline to determine if the state had made enough progress, he said it would take another year to fix Angola’s health care system.

The state’s medical expert, Dr. George Karam, initially agreed, telling the court he found Puisis’ “analysis and interpretations to be accurate.”

But Karam reversed his position 33 days later. In a report to Polozola, he noted that his employer, the Louisiana State University Medical School, was about to sign a three-year contract to provide health care services at the prison for $43,200 per month. This, he said, “created an additional comfort zone for me and has made me confident that we can achieve everyone’s stated goal of quality medical care” at Angola.

In March 1999, after less than six months of oversight, Polozola decided the state had done enough. He freed it from any further obligations and dismissed the case. The Justice Department did not object to the judge’s ruling.

The Justice Department declined interview requests for the attorneys who had been involved with the case and didn’t respond to questions about the settlement. Puisis declined an interview request. Karam did not respond to multiple requests for comment submitted to him and his office.

Attorney Keith Nordyke, who represented inmates in the lawsuit, said he understands why they were so angry; he remains disappointed himself. By the time of the settlement, he said, his role in the case was secondary to the Justice Department, so he didn’t have much of a say. Even so, he said, “with the PLRA right there, what leverage did I have?” When the law passed, he said, it felt like “the day of prison reform was coming to a close.”

Lawsuits Tossed Nationwide

One measure in the PLRA that has proven to be a significant obstacle for inmates was a requirement that they exhaust options within their prison’s grievance system before filing suit. In order to assert they had been beaten or raped by guards, or denied vital medical care, inmates first had to seek remedies from within the same system that they contended had harmed them. “It really is a case of the fox guarding the henhouse,” Fathi said.

Some corrections officials responded by making their grievance process more onerous: Illinois reduced the time inmates had to file complaints from six months to 60 days, according to an investigation by WBEZ and ProPublica. Other states threw out complaints “for tiny technical violations, like writing in the wrong color ink,” WBEZ and ProPublica reported.

That rule has caused cases to be thrown out even when inmates allege egregious abuse or misconduct. In 2003, more than a dozen female prisoners filed a lawsuit against the state of New York, claiming they had been subjected to “forcible rape, coerced sexual activity, oral and anal sodomy, and forced pregnancies,” according to Human Rights Watch. The state argued that the women hadn’t gone through the entire grievance process first, and the case was dismissed for that reason. An appeals court partially overturned the ruling because three inmates had exhausted their grievance options. The suit was eventually settled.

Thirteen years later, a guard at the Clarence N. Stevenson Unit, a state prison near the Texas Gulf Coast, slammed an inmate into a concrete floor, according to a federal lawsuit. The man lay in a coma in a hospital for two weeks, the Houston Chronicle reported. Texas had a 15-day deadline for inmates to file a grievance; the inmate, Candelario Hernandez, failed to meet it because he was unconscious.

A federal judge granted the state’s motion to dismiss the suit because Hernandez hadn’t gone through the grievance process. But because the state said in court that it would have considered a late grievance, the judge granted Hernandez two months to file one. After the state promptly rejected those grievances, the judge reversed his order to dismiss the case. The state’s denial was proof, he wrote, that the grievance process was a “dead end.” The suit is pending.

The current lawsuit over Angola’s medical care may be the latest to fall to the PLRA, even though Dick found that there was considerable evidence of failures. In a hearing, a plaintiffs’ lawyer said medical experts had found that 26 of 28 deaths at Angola had “serious medical errors and/or were preventable.” The lawyer said those experts had concluded that Angola’s delivery of medical care was among the worst they had ever reviewed. The state, however, argued that 21 deaths couldn’t have been prevented; it said most of those inmates had serious health problems and were treated properly, some refused treatment, and others had exacerbated their health problems by smoking.

Puisis, the plaintiffs’ medical expert in the 1992 lawsuit, is serving in the same role in the current case; he has found many of the same problems he identified in the 1990s. Dick noted this when she ruled for the plaintiffs in 2021: “Given the fact that many of the complaints in this lawsuit … are the same as those ‘settled’ in 1998, the Court finds that Defendants have been aware of these deficiencies in the delivery of medical care at LSP for decades,” she wrote.

But in the hearing before the 5th U.S. Circuit Court of Appeals this year, Louisiana Attorney General Liz Murrill complained that Dick has never given Angola officials credit, “at any stage,” for the improvements they have made, which she said include the addition of air conditioning in several medical dorms. (Neither her office nor the Department of Corrections responded to questions about the two lawsuits.)

Murrill also rejected Dick’s conclusion that Angola’s medical care was inadequate, saying the state “never conceded there was a violation in the first place.” She argued that the judge’s decision to appoint monitors to oversee reforms infringed on the state’s ability to operate its prisons. “And the PLRA says, ‘Don’t do that,’” Murrill added.

The 5th Circuit could uphold or reverse Dick’s ruling, or it could send it back to her to rehear the case, which could include legal arguments over whether her ruling follows the PLRA.

Circuit Judge Edith Jones, who was appointed in 1985 by President Ronald Reagan, echoed the state’s arguments in the hearing, saying that Angola prison for too long has “been under a Damocles sword imposed by the federal courts.” If inmates got their way and independent monitors were appointed to oversee the prison’s medical care, she said, the state would have to “jump at every turn and do precisely what they say.”

One of the lawyers for the inmates, Lydia Wright of the Promise of Justice Initiative, said she disagreed with that characterization of Dick’s ruling given that the state has failed to fix these problems over three decades. “We’re not talking about anything fancy, or exotic or wild,” Wright said. “We’re talking about basic medical care.”